EMPLOYEE ENROLLMENT PACKET

[Pages:30]EMPLOYEE ENROLLMENT PACKET

CON DU ENT P.O. Box 27460 Albuquerque, NM 87125-7460 Toll Free: (866) 916-0310

Table of Contents

Or

"What's Inside"

1) Important Information a) Contact Reference Guide b) Legally Responsible Individuals

2) Employee Enrollment Forms a) Employee Information Form b) Employment Agreement c) Declaration of Relationship d) Federal W-4 Tax Withholding F o r m e) New Mexico State Withholding Form f) Form l ?9-Employment Eligibility Verification g) Direct Deposit Authorization Form

3) Payroll Forms and Information a) Guidelines for Reporting Hours and Getting P ai d b) Employee Timesheet c) Payment Schedule

Contact Reference Guide "Who We Are"

CONDUENT has been contracted by the State of New Mexico to provide services as a Fiscal Management Agent (FMA) for participants in the Mi Via Program and members in the Self-Direction Program. CONDUENT has subcontracted portions of that contract to TNT Fiscal Intermediary (TNTFI) and FOCoS Innovations. As the FMA, one of our principal responsibilities is to assist participants and members that are employers to process payroll for their employees so that they are paid for the services they provide.

You've received this employee packet because you currently are or are about to become an employee for a Mi Via participant or Self-Direction member. This packet contains the forms that are necessary for you to complete in order to get paid. You must complete and return all of the required forms in this packet before you can become an employee under the Mi Via or Self-Direction program and receive payment for your services. We have provide instructions, illustrations, and additional information designed to assist you in this process. We have also included information you will need to know about the processes involved in reporting your hours and for you to get paid.

We understand that not every question can be covered in advance and CONDUENT is available to answer your questions. If you have questions, need additional information or otherwise need to contact CONDUENT regarding issues related to your employment through the Mi Via or Self-Direction program, please note the following contact information:

Mailing Address: CONDUENT PO Box 27460

Albuquerque, NM 87125-7460

Physical Address: CON DU ENT

1720-A Randolph Road SE Albuquerque, NM 87106

Phone Numbers: Toll Free-(866) 916-0310

Fax - (866) 302-6787

Email: mi. via@ Please do not send personal or protected health information via email.

Legally Responsible Individual

Legally Responsible Individuals may be hired and paid for waiver services under extraordinary circumstances to assure the health and welfare of the participant/member and to avoid institutionalization.

A Legally Responsible Individual (LRI) is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child, or, (b) a spouse of a waiver participant/member. Before an LRI can be paid for services provided to a Self-Direction waiver participant/member, the need to provide the services must be justified in a written request and submitted for State approval. The request must be approved by the State before a Self-Direction participant/member sends in their Service and Support Plan (SSP) and budget for review and must be renewed annually before the participants/members SSP is renewed ..

IF YOU ARE AN LRI PLEASE BE SURE TO PROVIDE A COPY OF THE APPROVAL FROM THE STATE. YOU WILL NOT BE PAID FOR SERVICES IF THE APPROVAL FORM IS NOT RECEIVED BY CONDUENT.

Form Description and Checklist

NEW HIRE FORMS

Employee Information Form (Required). This form will supply your basic demographic information to CONDUENT so we may establish your employee record in our database.

Employment Agreement (Required). This document establishes the particular details of your employment with each individual employer you work with.

Declaration of Relationship (Required). Federal tax law contains exemptions from specific payroll tax withholdings based on certain familial relationships between the employee and the employer. Information on this form is used to properly apply the law.

Federal W-4 Tax Withholding Form (Required). Complete this form to notify us of the number of exemptions you will claim for Federal tax withholding purposes.

State W-4 Tax Withholding Form (Required if different from Federal W-4). Complete this form to notify us of the number of exemptions you will claim for State tax withholding purposes.

1-9 Employment Eligibility Verification Form (Required). Please read carefully the instructions and included illustrated guide for information on completing this form. Both the employee and employer are responsible for completing this form. The employee is responsible for completing Section 1 and the employer for completing the information in Section 2. Both must sign the form.

Direct Deposit Authorization (Optional). Complete this form if you would prefer to have your checks deposited directly to your bank account.

Publication 797 Earned Income Credit (Optional). Publication 797 provides you with information regarding the IRS Earned Income Credit. If you have read the publication and would like to receive earned income credit through your paycheck, please contact CONDUENT or the IRS to receive form W-5.

You must complete and return all required and any optional forms to CONDUENT before you can be paid through the Self-Direction program.

TNT Fiscal Intermediary Services, Inc. Fiscal Agent

EMPLOYEE INFORMATION FORM

Member/Participant Name:

Required

(Last)

Employer of Record Name:

Required

(Last)

Employee Name:

(Last)

Social Security Number:

Mailing Address:

City:

Physical Address:

City:

County:

Home Phone: (

)

Cell Phone: (

)

Fax Number: (

)

Email Address:

Email Address (2):

(First)

(MI)

(First)

(MI)

(First)

(MI)

Date of Birth:

State:

Zip Code:

State:

Zip Code:

Employer: If an employee has a name change, the employee will need to complete and send a new W-4, a copy of their Social Security Card that reflects the name change and Employee Change Form to CONDUENT.

Employer of Record Signature:

Date:

Employee Signature:

Date:

EMPLOYMENT AGREEMENT Self-Direction Medicaid Waiver

Please check the appropriate box to indicate the purpose of the submission of this form. New Employee

Employee Pay (Rate) Change Effective Date of Rate Change

Note: CONDUENT must receive the Employment Agreement at least 15 days before any rate change. Rate changes will become effective at the beginning of the pay period. =================================================================== An employee is hired and supervised directly by the Employer of Record (EOR). The employee must follow the policies stated in this Agreement. The purpose of this Agreement is to establish the responsibilities of each party. The employee is an employee at will. The SelfDirection member/participant served under this Agreement is: (please print) (MEMBER/PARTICIPANT Name) ________________________________________________ Parties to Agreement This Employment Agreement is made on (Date) ___________________, by and between

(EMPLOYEE Name) ______________________________________________, hereinafter called "employee" and

(EOR Name) ____________________________________________________ hereinafter called "Employer."

EMPLOYEE Address:

Street: _________________________________________________________________

City______________________________________________State__________________ Phone ( )_______________________________

Empl. Agreement, 01/01/17 Employee's initials__________ EOR's initials__________

Page 1 of 8

Under 8.314.6.7 NMAC and 8.308.12 K. NMAC, a Legally Responsible Individual (LRI) is defined as any person who has a duty under state law to care for another person. This category typically includes: the parent (biological, legal or adoptive) of a minor child; the guardian of a minor child who must provide care to the child; or a spouse. State approval must be obtained in order for an LRI to be paid for providing Self-Direction services.

FOR MI VIA EMPLOYEES ONLY

Is the employee legally responsible for the Mi Via member/participant? _____ YES _____NO

If the employee is legally responsible for the Mi Via member/participant, please mark the box that best describes the employee's relationship to the member/participant:

Parent (biological, legal or adoptive) of member/participant who is a minor

Guardian of member/participant who is a minor

Spouse of the member/participant

If the employee is a Legally Responsible Individual (LRI) for the Mi Via member/participant, State approval to be a paid provider must be submitted with the employment agreement. If the LRI will be a provider for more than one service, State approval must be submitted for each service.

Job Duties The employer and employee will agree on a specific set of job duties or services to be provided. These duties and services will be developed in compliance with the definitions of Service Standards, and the Centennial Care Managed Care Policy Manual and will be documented on the member/participant's Mi Via Service and Support Plan (SSP) or SelfDirected Community Benefit (SDCB) Care Plan.

Payment The SSP, or SDCB Care Plan start date sets the date from which payments may begin. The rate of payment and hours/units must not exceed funding within the approved budget's line item. Only the approved rate will be paid. The employee shall be paid for his or her services at the following hourly rates (From the Self-Direction Budget):

Service Code __________ Rate $________*Estimated hours/units_______ per week/month (Circle)

Service Code __________ Rate $________ *Estimated hours/units_______ per week/month (Circle)

Service Code __________ Rate $________ *Estimated hours/units_______ per week/month (Circle)

Empl. Agreement, 01/01/17 Employee's initials__________ EOR's initials__________

Page 2 of 8

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